JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
2 Free N95 Masks & 1 Antigen Test Mailed to you
If you would like to have 2 3M Aura N95 masks mailed to you and/or 1 free FlowFlex anitgen test mailed to you, free of charge, please fill out the following information.
You are under no obligation to report test results to anyone.
Please consult the
CDC Guidance on self-testing
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Masks
I would like two free 3m Aura N95 masks mailed to me
I would like one free Flowflex antigen test mailed to me
First name
Your answer
Last name
Your answer
Affiliation
Your answer
Address 1
Your answer
Address 2
Your answer
City
Your answer
State
Your answer
Zip
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Lehigh University.
Report Abuse
Forms
